2012_1026CIIECK ONE_
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #!
LOCATION OF SERVICE: "•- �J'n1?rat.<-� �` Cc�'
The bacl. -flow prcvmtion assembly derailed below has bem tested and maintained � squired by TNRCC
re¢ulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
.� Double Check Valve
Manufacnaer s�7"%%(-��
Model Number ���p1 ]�_
serial Number [�/ / 3
TYPE OF ASSEMBLY
e Pressure Vacutmm Breaker
� Atmosphere Vacuum Breaker
Size
Located AL - - _
The above is certified to be true.
Fitm Name S •lit /� � /� - l �_
Firm Address ^/�Lvt/S z�-,�� � � '.
Gauge # �%�l!7�.J�S�
Date Ia_st accuracy tested ��� �� /�
Certified Tester
Cent. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Check
tad Cheek
Initial Test
DC- Closed
Tight Q
Closed Tight F3'
Leaked [J
Opined at
nsid
Opined at
nsid
vsid
RP- vsid
��� p
Did not Opm o
Leaked �
Repairs
and
Mata-ials
Used
Test Afies
Repair
DC- Closed
Tight �
Closed Tight O
Opined at
vsid
Opined at
nsid
nsid
Rp sid
The above is certified to be true.
Fitm Name S •lit /� � /� - l �_
Firm Address ^/�Lvt/S z�-,�� � � '.
Gauge # �%�l!7�.J�S�
Date Ia_st accuracy tested ��� �� /�
Certified Tester
Cent. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy